Blank Nevada Fa 6 PDF Template

The Nevada Fa 6 form is a Prior Authorization Request used by HP Enterprise Services for Nevada Medicaid and Nevada Check Up outpatient medical and surgical services. This form is essential for obtaining approval for necessary medical treatments and ensures that recipients receive the benefits they are entitled to. To get started, please fill out the form by clicking the button below.

Fill Out Nevada Fa 6

Structure

The Nevada FA 6 form is a crucial document for healthcare providers seeking prior authorization for outpatient medical and surgical services under the Nevada Medicaid and Nevada Check Up programs. This form facilitates the approval process by collecting essential information about the patient, the services requested, and the providers involved. It includes sections for recipient details, such as name, date of birth, and insurance information, ensuring that the request is linked to the correct individual. The form also requires information about the ordering and servicing providers, including their contact details and National Provider Identifier (NPI) numbers. Clinical information plays a vital role in this request; providers must outline the services sought, the medical necessity of these services, and any previous treatments or outcomes. Additionally, the form allows for the specification of whether the requested service relates to hospice benefits or Healthy Kids referrals. After submission, the review process determines whether the request is approved or denied, but it is important to note that this authorization does not guarantee payment. The confidentiality of the information provided is paramount, as indicated by the strict guidelines surrounding its use and dissemination.

Nevada Fa 6 Sample

Prior Authorization Request

HP Enterprise Services - Nevada Medicaid and Nevada Check Up

Outpatient Medical/Surgical

(Use Form FA-7 for Outpatient Rehabilitation and Therapy Services)

Fax this request to:	(866) 480-9903		For questions regarding this form, call: (800) 525-2395
DATE OF REQUEST: ______ /______ /________
REQUEST TYPE:	Initial	Continued Services	Retrospective*	Unscheduled Revision

*REQUIRED FOR RETROSPECTIVE REVIEWS ONLY

This recipient was determined eligible for Medicaid benefits on: ______ /______ /________

RECIPIENT INFORMATION

Recipient Name (Last, First, MI):

Recipient ID:				DOB:
Address:				Phone:
City:		State:		Zip Code:
Medicare Insurance Information:	Part A	Part B	Medicare ID#:
Other Insurance Name:			Other Insurance ID#:

Responsible Party Name (if applicable):

Responsible Party Address:

Phone:

ORDERING PROVIDER INFORMATION

Ordering Provider Name:

NPI:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Contact Name:

SERVICING PROVIDER INFORMATION

Servicing Provider Name:

NPI:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Contact Name:

CLINICAL INFORMATION (attach additional sheets if necessary)

No. of

HP ENTERPRISE

Code

SERVICES USE ONLY

Units

Description of Service

Requested

Units

Requested

Status

Action Code

Approved


FA-6	Page 1 of 2
10/01/11

Prior Authorization Request

HP Enterprise Services - Nevada Medicaid and Nevada Check Up

Outpatient Medical/Surgical

(Use Form FA-7 for Outpatient Rehabilitation and Therapy Services)

Is the service you are requesting a hospice benefit?	Yes	No
Are you requesting Healthy Kids (EPSDT) referral/services?		Yes	No
Conditions/Symptoms (include ICD-9 codes and descriptions):

Previous Treatment/Services (include dates):

Results of Previous Treatment/Services:

Other Clinical Information (to support medical necessity of the requested services):

HP ENTERPRISE SERVICES USE ONLY

Approved From:	Approved Through:
Denied From:	Denied Through:
Reviewer Signature:		Date:

This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms, limitations, exclusions, coordination of benefits and other terms and conditions set forth by the benefit program. The information on this form and on accompanying attachments is privileged and confidential and is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the employee or agent responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If this communication is received in error, the reader shall notify sender immediately and destroy all information received.


FA-6	Page 2 of 2
10/01/11

Click for Nevada Fa 6 PDF

File Attributes

Fact Name	Details
Form Purpose	The Nevada FA-6 form is used to request prior authorization for outpatient medical and surgical services under Nevada Medicaid and Nevada Check Up.
Submission Method	This form must be faxed to (866) 480-9903 for processing.
Contact Information	For questions about the form, individuals can call (800) 525-2395 for assistance.
Governing Law	The Nevada FA-6 form is governed by Nevada Revised Statutes (NRS) Chapter 422, which relates to public assistance and Medicaid.

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